A new CDC guideline on prescribing opioids for chronic pain has only added to the media attention being focused on opioid abuse and addiction. But what does the guideline really offer?

CDC Guideline for Prescribing Opioids for Chronic Pain

Objective: To synthesise the evidence for effectiveness of initiatives aimed at improving food retail environments and consumer dietary behaviour in rural, regional and remote populations in Australia and comparable countries, and to discuss the implications for future food environment initiatives for rural, regional and remote areas of Australia.

https://onlinelibrary.wiley.com/doi/pdf/10.5694/mja2.50881

Beyond the black stump: rapid reviews of health research issues affecting regional, rural and remote Australia.

Although collaborative care (CoCM) is an evidence-based and widely adopted model, reimbursement challenges have limited implementation efforts nationwide. In recent years, Medicare and other payers have activated CoCM-specific codes with the primary aim of facilitating financial sustainability. To investigate and describe the experiences of early adopters and explorers of Medicare’s CoCM codes. Fifteen interviews were conducted between October 2017 and May 2018 with 25 respondents representing 12 health care organizations and 2 payers. Respondents included dually boarded medicine/psychiatry physicians, psychiatrists, primary care physicians (PCPs), psychologists, a registered nurse, administrative staff, and billing staff. A semi-structured interview guide was used to address health care organization characteristics, CoCM services, patient consent, CoCM operational components, and CoCM billing processes. All interviews were recorded, transcribed, coded, and analyzed using a content analysis approach conducted jointly by the research team. Successful billing required buy-in from key, interdisciplinary stakeholders. In planning for CoCM billing implementation, several organizations hired licensed clinical social workers (LICSWs) as behavioral health care managers to maximize billing flexibility. Respondents reported a number of consent-related difficulties, but these were not primary barriers. Workflow changes required for billing the CoCM codes (e.g., tracking cumulative treatment minutes, once-monthly code entry) were described as arduous, but also stimulated creative solutions. Since CoCM codes incorporate the work of the psychiatric consultant into one payment to primary care, organizations employed strategies such as inter-departmental ledger transfers. When challenges arose from variations in the local payer mix, some organizations billed CoCM codes exclusively, while others elected to use a mixture of CoCM and traditional fee-for-service (FFS) codes. For most organizations, it was important to demonstrate financial sustainability from the CoCM codes. With deliberate planning, persistence, and widespread organizational buy-in, successful utilization of newly available FFS CoCM billing codes is achievable.

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Early Health System Experiences with Collaborative Care (CoCM) Billing Codes: a Qualitative Study of Leadership and Support Staff

Objectives To systematically identify knowledge clusters and research gaps in the health-related preferences of older patients with multimorbidity by mapping current evidence. Design Evidence map (systematic review variant). Data sources MEDLINE, EMBASE, PsycINFO, PSYNDEX, CINAHL and Science Citation Index/Social Science Citation Index/-Expanded from inception to April 2018. Study selection Studies reporting primary research on health-related preferences of older patients (mean age ≥60 years) with multimorbidity (≥2 chronic/acute conditions). Data extraction Two independent reviewers assessed studies for eligibility, extracted data and clustered the studies using MAXQDA-18 content analysis software. Results The 152 included studies (62% from North America, 28% from Europe) comprised 57 093 patients overall (range 9–9105). All used an observational design except for one interventional study: 63 (41%) were qualitative (59 cross-sectional, 4 longitudinal), 85 (57%) quantitative (63 cross-sectional, 22 longitudinal) and 3 (2%) used mixed methods. The setting was specialised care in 85 (56%) and primary care in 54 (36%) studies. We identified seven clusters of studies on preferences: end-of-life care (n=51, 34%), self-management (n=34, 22%), treatment (n=32, 21%), involvement in shared decision making (n=25, 17%), health outcome prioritisation/goal setting (n=19, 13%), healthcare service (n=12, 8%) and screening/diagnostic testing (n=1, 1%). Terminology (eg, preferences, views and perspectives) and concepts (eg, trade-offs, decision regret, goal setting) used to describe health-related preferences varied substantially between studies. Conclusion Our study provides the first evidence map on the preferences of older patients with multimorbidity. Included studies were mostly conducted in developed countries and covered a broad range of issues. Evidence on patient preferences concerning decision-making on screening and diagnostic testing was scarce. Differences in employed terminology, decision-making components and concepts, as well as the sparsity of intervention studies, are challenges for future research into evidence-based decision support seeking to elicit the preferences of older patients with multimorbidity and help them construct preferences. Trial registration number Open Science Framework (OSF): DOI 10.17605/OSF.IO/MCRWQ.

/pdf/health-related-preferences-of-older-patients-with-y9m63hu6v4.pdf

Health-related preferences of older patients with multimorbidity: An evidence map

Background: Depression is common in the primary care setting and tobacco use is more prevalent among individuals with depression. Recent research has linked smoking to poorer outcomes of depression treatment. We hypothesized that in adult primary care patients with the diagnosis of depression, current smoking would have a negative impact on clinical outcomes, regardless of treatment type (usual primary care [UC] vs collaborative care management [CCM]). Methods: A retrospective chart review study of 5155 adult primary care patients with depression in a primary care practice in southeast Minnesota was completed. Variables obtained included age, gender, marital status, race, smoking status, initial Patient Health Questionnaire-9 (PHQ-9), and 6-month PHQ-9. Clinical remission (CR) was defined as 6-month PHQ-9 <5. Persistent depressive symptoms (PDS) were defined as PHQ-9 ≥10 at 6 months. Treatment in both CCM and UC were compared. Results: Using intention to treat analysis, depressed smokers treated with CCM were 4.60 times as likely (95% CI 3.24-6.52, P < .001) to reach CR and were significantly less likely to have PDS at 6 months (adjusted odds ratio [AOR] 0.19, 95% CI 0.14-0.25, P < .001) compared with smokers in UC. After a 6-month follow-up, depressed smokers treated with CCM were 1.75 times as likely (95% CI 1.18-2.59, P = .006) to reach CR and were significantly less likely to have PDS (AOR 0.45, 95% CI 0.31-0.64, P < .001) compared with smokers in UC. Conclusions: CCM significantly improved depression outcomes for smokers at 6 months compared with UC. However, in the UC group, smoking outcomes were not statistically different at 6 months for either remission or PDS. Also, nonsmokers in CCM had the best clinical outcomes at 6 months in both achieving clinical remission and reduction of PDS when compared with smokers in UC as the reference group.

https://journals.sagepub.com/doi/pdf/10.1177/2150132719861265

Depression Outcomes in Smokers and Nonsmokers: Comparison of Collaborative Care Management Versus Usual Care.

A Model for Improving Adherence to Prescribing Guidelines for Chronic Opioid Therapy in Rural Primary Care

Introduction: Team-based care has become an essential part of modern medical practice. Patient-centered medical homes often struggle to balance the dual competing goals of acute access and continuity of care. Multimorbidity patients may value continuity more than healthy patients, and thus may prefer to wait to see their primary care physician (PCP). Methods: A total of 1700 randomly selected healthy adults and multimorbidity patients were asked to rate satisfaction with care and presented with 4 acute and 4 chronic scenarios to choose an access and continuity preference in an anonymous mailed survey. Results: In all, 770 responses were obtained. All respondents preferred to be seen 2.5 days sooner for acute appointments. Multimorbidity patients preferred to wait 0.28 days longer for acute issues to see their PCP. Patients who were not satisfied with their care team preferred to wait 0.75 days to see their PCP. Those not satisfied with their PCP choose to be seen 0.38 days sooner by their care team or any...

How Preferences for Continuity and Access Differ Between Multimorbidity and Healthy Patients in a Team Care Setting

PURPOSE Clinical provider peer review (CPPR) is a process for evaluating a patient's experience in encounters of care. It is part of ongoing professional practice evaluation and focused professional practice evaluation-important contributors to provider credentialing and privileging. Critical access hospitals are hindered in CPPR by having a limited number of providers, shortages of staff resources, and relationships among staff members that make unbiased review difficult. Small departments within larger institutions may face similar challenges. METHODS A CPPR process created at Mayo Clinic Health System is described. It involved a case review questionnaire built on the Institute of Medicine "Six Aims for Changing the Health Care System," a standardized intervention algorithm and tracking tool. OUTCOMES During 2007 through 2014, a total of 994 cases were reviewed; 31% led to provider dialog and education or intervention. Findings were applied to core measure processes with success rate going from 87% to 97%. Changes were adopted in end-of-life care, contributing to a 50% reduction in all-cause mortality rate. CONCLUSIONS Providing peer review tools to a critical access hospital can keep peer review within a group with knowledge of the individual provider's practice and can make process improvement the everyday work of those involved.

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A Systematic Approach to Clinical Peer Review in a Critical Access Hospital.

The use of cannabis products to help with sleep and various other medical conditions by the public has increased significantly in recent years. Withdrawal from cannabinoids can lead to sleep disturbance. Here, we describe a patient who developed significant insomnia leading to worsening anxiety, mood, and suicidal ideation in the setting of medical cannabis withdrawal, prompting presentation to the Emergency Department and inpatient admission. There is a limited evidence base for the use of cannabis products for sleep. We provide a comprehensive review evaluating the literature on the use of cannabis products on sleep, including an overview of cannabis and related psychoactive compounds, the current state of the law as it pertains to the prescribing and use of these substances, and potential side effects and drug interactions. We specifically discuss the impact of cannabis products on normal sleep and circadian sleep-wake rhythms, insomnia, excessive daytime sleepiness, sleep apnea, parasomnias, and restless legs syndrome. We also describe the effects of cannabis withdrawal on sleep and how this increases relapse to cannabis use. Most of the studies are observational but the few published randomized controlled trials are reviewed. Our comprehensive review of the effects of cannabis products on normal sleep and sleep disorders, relevant to primary care providers and other clinicians evaluating and treating patients who use these types of products, shows that cannabis products have minimal to no effects on sleep disorders and may have deleterious effects in some individuals. Further research examining the differential impact of the various types of cannabinoids that are currently available on each of these sleep disorders is required.

The Effects of Cannabinoids on Sleep

Opioid use disorder (OUD) is a cause of significant morbidity and mortality in the United States. Although efforts are being made to limit access to prescription opioids, the use of heroin and synthetic opioids as well as death due to opioid overdose has increased. Medication-assisted treatment (MAT) is the pairing of psychosocial intervention with a Food and Drug Administration (FDA)-approved medication (methadone, buprenorphine plus naltrexone) to treat OUD. MAT has resulted in reductions in overdose deaths, criminal activity, and infectious disease transmission. Access to MAT in rural areas is limited by shortages of addiction medicine-trained providers, lack of access to comprehensive addiction programs, transportation, and cost-related issues. Rural physicians express concern about lack of mentorship and drug diversion as reasons to avoid MAT. The prescribing of MAT with buprenorphine requires a Drug Enforcement Agency (DEA) waiver that can easily be obtained by Family Medicine providers. MAT can be incorporated into the outpatient practice, where patient follow-up rates and number needed to treat to effect change are similar to that of other chronic medical conditions. We describe a case of opioid overdose and a suggested protocol for the induction of MAT with buprenorphine/naloxone (Suboxone) for OUD in a rural family medicine outpatient practice. Treatment access is facilitated by utilizing the protocol, allowing office staff work to the extent allowed by their licensure, promoting teamwork and minimizing physician time commitment. We conclude that improved access to MAT can be accomplished in a rural family medicine outpatient clinic by staff that support and mentor one another through use of a MAT protocol.

https://journals.sagepub.com/doi/pdf/10.1177/2150132720931720

Mark E. Deyo-Svendsen

Papers

A Model for Improving Adherence to Prescribing Guidelines for Chronic Opioid Therapy in Rural Primary Care

How Preferences for Continuity and Access Differ Between Multimorbidity and Healthy Patients in a Team Care Setting

A Systematic Approach to Clinical Peer Review in a Critical Access Hospital.

The Effects of Cannabinoids on Sleep

Medication-Assisted Treatment for Opioid Use Disorder in a Rural Family Medicine Practice.